Inspection·June 14, 2023

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 6/13/2023 at 9:57 a.m., the Corporate Clinical Specialist stated the new company took over the facility on 4/01/2023 and that the old company had their stuff packed when they left and she could not find any resident council minutes from 2022 or from prior to April 2023. The Corporate Clinical Specialist The Corporate Clinical Specialist stated her team had been doing resident council since they took over the building. When asked who was responsible for ensuring the new company had access to the facility's documents, the Corporate Clinical Specialist stated she could find out. The Corporate Clinical Specialist stated the importance of having the facility's records was they could follow up on concerns and provide residents with better quality of life. The Corporate Clinical Specialist stated new systems were put in place on 4/01/2023 such as an open communication system. During an interview on 6/13/2023 at 10:55 a.m., the DON stated the previous company boxed up their own records and had shredder trucks come by to pick up the old records. During an interview on 6/13/2023 at 11:08 a.m., the Corporate Clinical Specialist stated the previous activity director may have had resident council minutes and may have put them into the electronic health records system the facility used previously prior to 4/01/2023. During a confidential meeting of residents, residents reported the Dietary Manager used to be the activity director and they did not have any resident council meetings because the Dietary Manager was busy in the kitchen. Residents stated the Dietary Manager was doing kitchen and activities but the facility kept losing cooks so she started working more in the kitchen. Residents stated the Dietary Manager would schedule resident council meetings but then she would have to end up working in the kitchen so the meetings would not happen as scheduled. Residents reported the previous administrator did not allow residents to meet at a good time that worked for them and stated the previous administrator never helped to facilitate resident council meetings. Residents stated the previous administrator would say tell them to talk to the Dietary Manager and then the Dietary Manager would schedule the meetings but the facility would be short on staff that day and the meetings would not occur as scheduled because there was no one available to get residents up. Residents reported when they did meet for resident council, it was in the dining room, which they stated was not very private because there were no doors between the dining room and the rest of the facility. Residents reported that the Activity Director had too many responsibilities because she did social work, was a driver, did marketing and activities. During an interview on 6/13/2023 at 4:05 p.m., the Administrator stated she had in-serviced staff because not having regular resident council meetings was inexcusable. The Administrator stated she found out from AD B, the previous activity director, that she had only done one resident council meeting because of COVID-19. During an interview on 6/13/2023 at 5:04 p.m., AD B stated she worked at the facility as the activity director from the middle of February 2023 until March 2023. AD B stated she tried to do a resident council meeting in February 2023 but no one showed up. AD B stated she facilitated a resident council meeting in March 2023 and left the resident council meeting notes on the desk in the activity room when she stopped working for the facility. AD B stated no that the previous administrator was not helpful with getting residents up for resident council. During an interview on 6/14/2023 at 8:29 a.m., the Therapy Coordinator stated July 2023 would mark eight years of her working in the facility. The Therapy Coordinator stated the facility did not do resident council meetings during covid and that they started doing them again in March 2023. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some asked if this meant there had not been any resident council meetings from 2020-2022, the Therapy Coordinator stated she did not remember the facility having any resident council meetings during that time because everyone was locked down for covid and they couldn't meet in groups. During an interview on 6/14/2023 at 11:25 a.m., the Activity Director stated she started working in the facility on 4/06/2023. The Activity Director stated she was responsible for organizing and accommodating resident council meetings. When asked why resident council did not meet on Wednesday 6/07/2023, as scheduled per the activity calendar, the Activity Director stated because Resident #14 was out of the facility on pass that day, Resident #13 was in bed all day, and because Resident #13 did not want to have the meeting without Resident #14. The Activity Director stated she usually tried to have resident council meetings on the first Tuesday of every month. During an interview on 6/14/2023 at 11:35 a.m., the Dietary Manager stated she had worked in the facility for 30 years in different positions and worked as activity director before starting as Dietary Manager in October of 2022. The Dietary Manager stated when she was activity director, she worked on and off in the kitchen. The Dietary Manager stated from January 2022 onward, she was doing both activities and kitchen but was mostly working in the kitchen. The Dietary Manager stated she coordinated resident council meetings but sometimes they did not have them because she was always stuck in the kitchen. During an observation and interview on 6/14/2023 beginning at 11:53 a.m., Resident #14 was observed lying in bed. Resident #14 stated she only went out of the facility on pass on Tuesdays and Fridays, and that was why resident council was scheduled for Wednesday. When asked why resident council did not meet as scheduled on 6/07/2023, Resident #14 stated because the Activity Director probably was not in the facility that day and I can't make the nurses get everyone up. Resident #14 stated the facility gave the Activity Director too many jobs to do so she did not have the time or energy to set up resident council. During an interview on 6/14/2023 at 3:33 p.m., the DON stated she started working in the facility on 4/20/2023, was still learning the policies, but knew they were supposed to have resident council every month. The DON stated the Activity Director was responsible for planning and coordinating resident council meetings. When asked how the facility assisted with planning and coordinating resident council meetings, the DON stated the day of resident council, the Activity Director would announce it to residents and then all of us will make sure they're toileted and get up. The DON stated nursing staff assisted residents to get up for meetings. The DON stated she did not do anything with resident council and when asked who oversaw staff to ensure resident council was meeting, the DON stated, I will defer to the Administrator because I'm the DON. The DON stated yes that she felt there were enough staff to get residents up for resident council. The DON stated resident council met in the dining room. When asked if the dining room was private and whether it had a door to shut it off from the rest of the facility, the DON stated there was not and she stated she guessed that was a consideration they would have to discuss. The DON stated if resident council did not meet regularly, residents would not be able to share their ideas, plan meal of the month, plan activities, and their voices would not be heard. During an interview on 6/14/2023 at 4:54 p.m., the Administrator stated resident council was a big deal and was very important to residents and important for finding out what residents needed and what their complaints were. The Administrator stated, if you don't do resident council, you can't make residents happy. The Administrator stated the Activity Director was the one who coordinated and held resident council, and that she was new to the role. The Administrator stated the Activity Director (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some did activities and social work and when asked f she had enough time to do both, the Administrator stated it was difficult. The Administrator stated when the census reached 40 residents, the facility would split those roles and have both a social worker and an activity director. The Administrator stated she expected resident council to meet every month or more often if residents wanted. The Administrator stated she was responsible for ensuring resident council was done. When asked why resident council had not met as scheduled on 6/07/2023, the Administrator stated that was her first time hearing about it and that the Activity Director had been out of the facility doing marketing. The Administrator stated the Activity Director did marketing, social work, activities and admissions. The Administrator stated the Activity Director was out doing marketing on Wednesday 6/07/2023 but that resident council still should have happened. The Administrator stated someone should have stepped in, she should have stepped up, and there was a breakdown in communication. During an observation and interview on 6/14/2023 beginning at 4:19 p.m., Resident #13 was observed lying in bed. Resident #13 stated he was the vice president of resident council. When asked why resident council did not meet the week prior on 6/07/2023, Resident #13 stated he did not know about it. Resident #13 stated if they did have meetings, no one wanted to get him up or no one felt like getting him up. Resident #13 stated no one had informed him that resident council was scheduled for 6/07/2023. Resident #13 stated no that he did not feel there were enough staff to get everyone up for resident council. Resident #13 stated he would have gone if he had been notified and sometimes he did not catch some of the notifications. A record review of the facility's activity calendar dated June 2023 reflected Resident Council Meeting was scheduled for 10:30 a.m. on 6/07/2023. A record review of resident council minutes from 2023 reflected resident council met on 4/14/2023 and on 5/03/2023. There were no meeting minutes for January 2023 - March 2023 or for June 2023. A record review of the facility's policy titled Resident Council dated February 2021 reflected the following: Policy Statement The facility supports residents' rights to organize and participate in the resident council. Policy Interpretation and Implementation 1. The purpose of the resident council is to provide a forum for: a. residents, families and resident representatives to have input in the operation of the facility; b. discussion of concerns and suggestions for improvement; c. consensus building and communication between residents and facility staff; and d. disseminating information and gathering feedback from interested residents. 2. All residents are eligible to participate in the resident council. The facility staff encourages residents who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0565 are willing to participate. Staff, visitors, or other guests may attend resident council meetings if invited by Level of Harm - Minimal harm or potential for actual harm the respective resident group. 3. The resident council group is provided with space, privacy and support to conduct meetings. Residents Affected - Some 5. Council meetings are scheduled monthly or more frequently if requested by residents. The date, time and location of the meetings are noted in the activities calendar. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview and record review, the facility failed to ensure residents had a safe, clean, comfortable and homelike environment for one of seven anonymous residents reviewed for homelike environment. The facility failed to ensure the shower room on the 300 hall was free of a black substance. This failure placed residents at risk of having an unclean environment. Findings included: During a confidential meeting on with residents on 6/13/2023, a resident reported the shower room on the 300-hall had mold. During an observation and interview on 6/13/2023 beginning 3:30 p.m., the shower room on the 300-hall appeared to have a black cloudy-looking substance in the cracks and corners of the floor where the floor met the wall on the right side of the shower room. CNA C stated he had not encountered mold before and did not know what the black substance was in the shower room but he did not think it was mold because he thought that would smell bad and there was no odor. CNA C stated housekeeping was supposed to clean the shower room every day but he was not sure whether they did because he was not there every day. CNA C stated he worked during the day and the shower room was in use during the mornings. During an interview on 6/13/2023 at 3:26 p.m., HK A stated she tried to clean the shower room every day and most of the time it got cleaned every day. HK A stated she cleaned the toilet, the seat residents sat on during showers, the shower bed, and the floor. HK A stated housekeeping staff scrubbed the shower with a brush. HK A stated she tried to clean the black dirt off but it did not come off. HK A stated she thought it was just old dirt but it could be mold. HK A stated she told the Housekeeping Supervisor about it and the Housekeeping Supervisor tried to use different techniques to remove it and it helped a little bit. HK A stated she thought the Housekeeping Supervisor had reported the concern to the Maintenance Supervisor. During an interview on 6/13/2023 at 3:33 p.m., the Housekeeping Supervisor stated she thought the black substance in the shower room on 300 hall was a mixture of mold and dirt. The Housekeeping Supervisor stated she first reported this to the Maintenance Director in October 2022 and he told her he would get to it. The Housekeeping Supervisor stated yes she believed eight months was too long for the issue to be resolved. The Housekeeping Supervisor stated she had not submitted a written work order for the issue but had communicated it via word of mouth to the Maintenance Supervisor. The Housekeeping Supervisor stated the shower room did get cleaned every day and she was the one who did it. The Housekeeping Supervisor stated lately she had been more of a full time driver for the facility more than anything and she felt her staff had become more laide back since she had starting driving and was not in the facility as often. The Housekeeping Supervisor stated she felt things had been slipping through the cracks. The Housekeeping Supervisor stated since the new company took over in April of 2023, she no longer completed her supply orders and it had been a fighting battle to get things she needed such as the right trash bags. The Housekeeping Supervisor stated she used the pink stuff to clean the dirt in the shower room and these chemicals were left over from the previous company-she did not explain what kind of cleaner the pink stuff was. The Housekeeping Supervisor stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had bought a lot of stuff for the facility out of her pocket. The Housekeeping Supervisor stated she had told the Administrator the shower room floors were really bad. The Housekeeping Supervisor stated when someone in the past had made an allegation about there being mold in the kitchen, the facility had a crew come in and deep clean the kitchen but no one has done that for the shower room. The Housekeeping Supervisor stated yes that all 27 residents used that shower room. The Housekeeping Supervisor stated she had not given many in-services to housekeeping staff because she did not have any in-service templates to pull like she used to since the old company left. The Housekeeping Supervisor stated she was told to use CDC data to train housekeeping staff. The Housekeeping Supervisor stated she did not feel like she had everything she needed to be successful. During an interview on 6/13/2023 at 4:50 p.m., the Maintenance Director stated he started working in the facility in 2016 or 2017 and stopped working his position full time in January 2023 due to health concerns. The Maintenance Director stated he had put in a resignation in May 2023 and 6/02/2023 was supposed to be his last day working in the facility, but he continued to work there when he could because he liked the residents. The Maintenance Director stated the Housekeeping Supervisor had never reported to him a maintenance issue about the shower room on 300 hall. The Maintenance Director stated he usually only went in the shower room to fix the toilet. During an interview and observation of the 300-hall shower room on 6/13/2023 beginning at 5:01 p.m., the Maintenance Director stated the black substance in the shower room looked like mildew. The Maintenance Director stated, I don't want to say it's mold and said he did not know the difference between mold and mildew. The Maintenance Director stated he monitored the building by checking lights and checking the perimeter of the building-he stated he did not monitor the shower room regularly and had never seen mildew. The Maintenance Directors stated he would expect housekeeping staff to monitor the shower room and let him know if there was mildew but the Housekeeping Supervisor had never reported that to him. The Maintenance Director stated he did not have mildew remover but he could go get some. During an interview on 6/14/2023 at 10:52 a.m., CNA D stated she had worked in the facility for about a month and had noticed the black substance in the shower room. CNA D stated, kinda sorta that she had first noticed when she started working in the facility. During an interview on 6/14/2023 at 3:33 p.m., the DON stated, we want [residents] to have a clean environment and have them safe and comfortable. The DON stated yes she had seen the shower room corners and floor and it was addressed immediately. The DON stated she first became aware of the issues the day prior (6/13/2023) when she observed staff being interviewed by a surveyor in the shower room. The DON stated she believed the black substance in the 300 hall shower room was mildew, that she went in there every day, and did not remember seeing it in the past. When asked if she believed having a black substance in the shower room was sanitary, the DON stated it did not take away from homelike environment and it's going to be on my rounds every day so it's not an issue. When asked if old dirt or a black substance seemed clean to her, the DON stated she had had mildew in her bathroom and that's not going to be an issue again. The DON stated that as the Infection Preventionist, she was responsible for monitoring the shower room to ensure it was clean and sanitary. When asked what a potential negative resident outcome was if shower rooms were not kept clean, the DON stated it would not happen again, there had not been any repercussions or skin issues, and she would have to research exposure to mildew. The DON stated, there haven't been any repercussions and there won't be because we'll take care of it. During an interview on 6/14/2023 at 4:52 p.m., the Administrator stated she began working in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675445 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Flatonia Healthcare Center 624 N Converse St Flatonia, TX 78941 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on 4/01/2023 and only recently had she been able to spend time out there. The Administrator stated the facility's policy on homelike environment included keeping the facility safe, homelike and sanitary and I think there are some areas we haven't gotten to yet. The Administrator stated yes she had seen the shower room corners and floors. The Administrator stated the Activity Director brought it to her attention about a week ago because she wanted to know if it looked like mold. The Administrator stated when she went into the shower room on the 300 hall there was a black substance concentrated in the grout and corners of the shower room but it was not fuzzy The Administrator stated she had not paid attention to the right side of the shower room until the day prior (6/13/2023) when CNA C brought it to her attention. The Administrator stated she did not believe old dirt or mildew in the shower room was unsanitary and for her, it was homelike. The Administrator stated housekeeping staff should be cleaning the shower room every day. The Administrator stated she made rounds in the facility daily but a lot of times the shower room door was shut. The Administrator stated nursing staff were the ones bathing residents so they needed to let us know if it needs extra attention. The Administrator stated it was everybody's responsibility to oversee cleanliness of the shower room and obviously we failed on that one. The Administrator stated that moving forward, she would check the showers every day. The Administrator stated mildew was a discoloration and mold was a growth. The Administrator stated if the substance in the shower room were mold, it could make people sick and if it were mildew, there could be an impact. The Administrator stated at home, she cleaned her bathroom because she did not want to leave mildew there and stated she did not want to leave it there for residents either. A record review of work orders from October 2022 to present (6/14/2023) reflected no work orders related to excessive dirt or a black substance in the shower room on 300-hall. A record review of the facility's policy titled Homelike Environment dated February 2021 reflected the following: Policy Statement Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675445 If continuation sheet Page 8 of 8